![]() Change of environment because of a hiking trip to the Appalachians is a potential external risk factor. As for internal risk factors, this group might include drinking alcohol nearly every night. There are both internal and external risk factors involved. In Mary’s case, it is the risk for further damage to skin layers. The motivation for this decision is that the patient is at risk for alteration in the epidermis and/or dermis (Herdman& Kamitsuru, 2014). In Mary’s case, the most likely presumptive nursing diagnosis is the risk for impaired skin integrity. Presumptive Nursing DiagnosisĪ nursing diagnosis is a clinical judgment about a patient, his or her family, environment, and reactions to health conditions. Lymph nodes: Neck supple, no cervical lymphadenopathy or thyromegaly.įocused Physical Examination: HEENT, Cardiac, Respiratory, Lymphatic systems and focus on skin. Skin: Several erythematous plaques scattered over the cheeks and the bridge of the nose, sparing the nasolabial folds.Ĭhest/lungs: No cough or shortness of breath. ![]() Head: Normocephalic head bone, atraumatic.Įyes: Sclera white, conjunctivae clear pupils constrict from 4 mm to 2 mm, equal, round, and reactive to light and accommodation.Įars, Nose, Mouth, Sinuses: shallow ulcers in the buccal mucosa bilaterally Oropharynx moist and erythema in the posterior pharyngeal wall. Full range of motion no swelling or deformity muscles with normal bulk and tone no exudates. Experiences fever, weakness, and fatigue. BP 112/66 mm Hg HR 62 BPM and regular respiratory rate 12 breaths/min temperature 100.3☏. General Constitutional systems: Alert young woman. Except for that, no other stories of health concerns in her family because her father is absolutely healthy. ![]() Nearly every evening the patient has a glass of wine with her meal, denies illicit drugs, does not smoke. She has a master’s degree in engineering. Except for that, no other stories of hospitalization because she was always healthy. Past Medical HistoryĪt age 9, Mary had a tonsillectomy because of chronic strep throat infections. No sign of joint stiffness in the morning. However, the patient denies cough, ear pain, headache, diarrhea, chest pain, sore throat, temperature intolerance, pain with urination, abdominal pain or pain with urination, nasal or sinus congestion, and shortness of breath, etc. As for other symptoms, she noticed weight loss, fever, increased fatigue, muscle aches, especially in wrist and hand, and mouth soreness.
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